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Since 2007, the Departments of Defense (DOD) and Veterans Affairs (VA) have been testing a new disability evaluation system designed to integrate their separate processes and thereby expedite veterans' benefits for wounded, ill, and injured servicemembers. Having piloted the integrated disability evaluation system (IDES) at 27 military facilities, they are now planning for its expansion military-wide. Part of the National Defense Authorization Act for Fiscal Year 2008 required GAO to report on DOD and VA's implementation of policies on disability evaluations. This report examines: (1) the results of the agencies' evaluation of the IDES pilot, (2) challenges in implementing the IDES pilot to date, and (3) whether DOD and VA's plans to expand the IDES adequately address potential future challenges. GAO analyzed data from DOD and VA, conducted site visits at 10 military facilities, and interviewed DOD and VA officials.

In their evaluation of the IDES pilot as of February 2010, DOD and VA concluded that it had improved servicemember satisfaction relative to the existing "legacy" system and met their established goal of delivering VA benefits to active duty and reserve component servicemembers within 295 and 305 days, respectively, on average. While these results are promising, average case processing times have steadily increased since the February 2010 evaluation. At 296 days for active duty servicemembers, as of August 2010, processing time for the IDES is still an improvement over the 540 days that DOD and VA estimated the legacy process takes to deliver VA benefits to members. However, the full extent of improvement of the IDES over the legacy system is unknown because (1) the 540-day estimate was based on a small, nonrepresentative sample of cases and (2) limitations in legacy case data prevent a comprehensive comparison of timeliness, as well as appeal rates. Piloting of the IDES has revealed several implementation challenges that have contributed to delays in the process, the most significant being insufficient staffing by DOD and VA. Staffing shortages were severe at a few pilot sites that experienced caseload surges. For example, at one of these sites, due to a lack of VA medical staff, it took 140 days on average to complete one of the key features of the pilot--the single exam--compared with the agencies' goal to complete this step of the process in 45 days. The single exam posed other challenges that contributed to process delays, such as exam summaries that did not contain sufficient information for VA to determine the servicemember's benefits and disagreements between DOD and VA medical staff about diagnoses for servicemembers' medical conditions. Cases with these problems were returned for further attention, adding time to the process. Pilot sites also experienced logistical challenges, such as incorporating VA staff at military facilities and housing and managing personnel going through the process. As DOD and VA prepare to expand the IDES worldwide, they have made preparations to address a number of these challenges, but these efforts have yet to be tested, and not all challenges have been addressed. To address staffing shortages and ensure timely processing, VA is developing a contract for additional medical examiners, and DOD and VA are requiring local staff to develop written contingency plans for handling surges in caseloads. However, the agencies lack strategies for meeting some key challenges, such as ensuring enough military physicians to handle anticipated workloads. They also do not have a comprehensive monitoring plan for identifying problems as they occur--such as staffing shortages and insufficiencies in medical exams--in order to take remedial actions as early as possible. GAO is making several recommendations to improve DOD and VA's planning for expansion of the new disability evaluation system, including developing a systematic monitoring process and ensuring that adequate staff is in place. DOD and VA generally concurred with GAO's recommendations and provided technical comments that GAO incorporated into the report as appropriate.

Recommendations for Executive Action

Status: Closed - Not Implemented

Comments: We reviewed the integrated disability evaluation system (IDES) in 2012 after the IDES had been implemented at all sites. We continued to find difficulties with ensuring adequate staffing of military physicians to complete medical evaluation board (MEB) determinations (GAO-12-676).

Recommendation: To ensure that the IDES is sufficiently staffed and that military treatment facilities are prepared to house personnel in the IDES, the Secretary of Defense should direct the military services to conduct thorough assessments prior to each site's implementation of the IDES of the adequacy of staffing of military physicians for completing medical evaluation board (MEB) determinations at military treatment facilities; contingency plans should be developed to address potential staffing shortfalls, for example, due to staff turnover or caseload surges.

Agency Affected: Department of Defense

Status: Closed - Implemented

Comments: DOD addressed the concern about housing of servicemembers undergoing the IDES by issuing an exception to policy authorizing military departments to process initial trainees through the legacy disability evaluation system, rather than the IDES process. In the action memo authorizing this exception, DOD said that this change was intended to address the issue of housing and other issues, due to the additional time that servicemembers remain on active duty when processed through the IDES as compared to the legacy system. The policy exception states that trainees who are processed through the legacy disability evaluation system will be enrolled in the Benefits Delivery at Discharge/VA Quick Start programs to ensure that that they begin receiving VA benefits shortly after separation from military service. DOD officials said that since the policy exception was issued, the military departments have not reported concerns with the capacity to house servicemembers in the IDES.

Recommendation: To ensure that the IDES is sufficiently staffed and that military treatment facilities are prepared to house personnel in the IDES, the Secretary of Defense should direct the military services to conduct thorough assessments prior to each site's implementation of the IDES of the availability of housing for servicemembers in the IDES at military facilities; alternative housing options should be identified if sites do not have adequate capacity.

Agency Affected: Department of Defense

Status: Closed - Implemented

Comments: DOD addressed the concern about military units' ability to absorb servicemembers undergoing the IDES by issuing an exception to policy authorizing the military departments to process initial trainees through the legacy disability evaluation system, rather than the IDES process. In the action memo authorizing this exception, DOD said that this change was intended to address challenges of command and control, housing, and other issues, due to the additional time that servicemembers remain on active duty when processed through the IDES as compared to the legacy system. The policy exception states that trainees who are processed through the legacy disability evaluation system will be enrolled in the Benefits Delivery at Discharge/VA Quick Start programs to ensure that that they begin receiving VA benefits shortly after separation from military service. DOD officials said that since the policy exception was issued, the military departments have not reported concerns with the ability to absorb servicemembers in the IDES.

Recommendation: To ensure that the IDES is sufficiently staffed and that military treatment facilities are prepared to house personnel in the IDES, the Secretary of Defense should direct the military services to conduct thorough assessments prior to each site's implementation of the IDES of the capacity of organizational units to absorb servicemembers undergoing the disability evaluation; plans should be in place to ensure servicemembers are appropriately and constructively engaged.

Agency Affected: Department of Defense

Status: Closed - Implemented

Comments: DOD contracted with the Logistics Management Institute (LMI) to conduct a study on differences in diagnoses in response to our recommendation. In October 2011, LMI completed the study entitled "Diagnostic Differences in the DOD-VA Integrated Disability Evaluation System."

Recommendation: To improve their agencies' ability to resolve differences about diagnoses of servicemembers' conditions, and to determine whether their new guidance sufficiently addresses these disagreements, the Secretaries of Defense and Veterans Affairs should conduct a study to assess the prevalence and causes of such disagreements.

Agency Affected: Department of Defense

Status: Closed - Implemented

Comments: DOD contracted with the Logistics Management Institute (LMI) to conduct a study on differences in diagnoses in response to our recommendation. In October 2011, LMI completed the study entitled "Diagnostic Differences in the DOD-VA Integrated Disability Evaluation System."

Recommendation: To improve their agencies' ability to resolve differences about diagnoses of servicemembers' conditions, and to determine whether their new guidance sufficiently addresses these disagreements, the Secretaries of Defense and Veterans Affairs should conduct a study to assess the prevalence and causes of such disagreements.

Agency Affected: Department of Veterans Affairs

Status: Closed - Implemented

Comments: VA updated the Veterans Tracking Application (VTA) in June 2012 to allow it and DOD to capture information on diagnostic disagreements. DOD subsequently provided training instructing PEB liaison officers to document disagreements using VTA's corrective action function. This information is used to generate weekly summaries, which can be used to spot trends in disagreements and adjust IDES processes and training accordingly. Before documenting diagnostic disagreements, the Army-which accounts for the majority of servicemembers in the IDES-has instructed its physicians to attempt to resolve disagreements with VA physicians. VA believes this has reduced the incidence of diagnostic disagreements.

Recommendation: To improve their agencies' ability to resolve differences about diagnoses of servicemembers' conditions, and to determine whether their new guidance sufficiently addresses these disagreements, the Secretaries of Defense and Veterans Affairs should establish a mechanism to continuously monitor disagreements about diagnoses between military physicians and VA examiners and between physical evaluation boards (PEB) and VA rating offices.

Agency Affected: Department of Veterans Affairs

Status: Closed - Implemented

Comments: VA updated the Veterans Tracking Application (VTA) in June 2012 to allow it and DOD to capture information on diagnostic disagreements. DOD subsequently provided training instructing PEB liaison officers to document disagreements using VTA's corrective action function. This information is used to generate weekly summaries, which can be used to spot trends in disagreements and adjust IDES processes and training accordingly. Before documenting diagnostic disagreements, the Army-which accounts for the majority of servicemembers in the IDES-has instructed its physicians to attempt to resolve disagreements with VA physicians. VA believes this has reduced the incidence of diagnostic disagreements.

Recommendation: To improve their agencies' ability to resolve differences about diagnoses of servicemembers' conditions, and to determine whether their new guidance sufficiently addresses these disagreements, the Secretaries of Defense and Veterans Affairs should establish a mechanism to continuously monitor disagreements about diagnoses between military physicians and VA examiners and between physical evaluation boards (PEB) and VA rating offices.

Agency Affected: Department of Defense

Status: Closed - Implemented

Comments: Since our report was issued, the IDES monitoring report was revised to include more detailed information, including case processing times of individual VA rating offices. VA also developed an IDES Performance Dashboard, which tracks performance data at the local level for portions of the IDES for which VA is responsible. With regard to timeliness of VA exams, VA developed a report to identify IDES exams exceeding the timeliness goal. Senior VA leadership hold biweekly videoconference calls to discuss how to remedy outliers. As for sufficiency of exam summaries, VA added capabilities to the Veterans Tracking Application system to identify exam sufficiency issues, and DOD is using this data to determine how often insufficient exam summaries occur, in what types of medical conditions, and the length of time it takes to identify and address them. DOD and VA also hold meetings on a biweekly basis to share lessons learned, problem solve, and keep sites aware of future program changes and activities.

Recommendation: To enable their agencies to take early action on problems at IDES sites postimplementation, the Secretaries of Defense and Veterans Affairs should develop a system-wide monitoring mechanism to identify challenges as they arise in all DOD and VA facilities and offices involved in the IDES. This system could include: (1) continuous collection and analysis of data on DOD and VA staffing levels, sufficiency of exam summaries, and diagnostic disagreements; (2) monitoring of available data on caseloads and case processing time by individual VA rating office and PEB; and (3) a formal mechanism for agency officials at local DOD and VA facilities to communicate challenges and best practices to DOD and VA headquarters offices.

Agency Affected: Department of Veterans Affairs

Status: Closed - Implemented

Comments: Since our report, DOD has revised its monitoring report to include more information, including information on case processing times of individual VA rating offices and PEBs. DOD also created an MEB Watchboard and PEB Watchboard to provide case management information, workload status, and the ability to monitor data integrity at local installations. DOD and VA have also revised the VTA tracking system to identify insufficient exam summaries. DOD has developed a method to use the data to determine how often insufficient exam summaries occur, in what types of medical conditions, and the length of time it takes to identify and address them. DOD and VA senior leadership also continue to hold meetings on a regular basis to discuss the status, progress, and future actions regarding the IDES. These include the Joint Executive Council, the Benefits Executive Council, the DES Improvement Working Group, and data summit sessions.

Recommendation: To enable their agencies to take early action on problems at IDES sites postimplementation, the Secretaries of Defense and Veterans Affairs should develop a system-wide monitoring mechanism to identify challenges as they arise in all DOD and VA facilities and offices involved in the IDES. This system could include: (1) continuous collection and analysis of data on DOD and VA staffing levels, sufficiency of exam summaries, and diagnostic disagreements; (2) monitoring of available data on caseloads and case processing time by individual VA rating office and PEB; and (3) a formal mechanism for agency officials at local DOD and VA facilities to communicate challenges and best practices to DOD and VA headquarters offices.